All right. Great. All right. Well, good morning, everybody. What an honor it is to be finding myself shoulder-to-shoulder with some of the thought leaders in meniscus repair and meniscus preservation surgery, and so I think that my charge here this morning is to provide some pearls, some tips and tricks, some things that I've gleaned over the course of the last several years that I've been in practice teaching residents, and then get out of the way and let these guys get into the good stuff. So no relevant financial disclosures. I thought I'd start by talking about what the stakes are and confirm what I think a lot of us in the audience know from the standpoint is why these things are so important. The stakes are extraordinarily high, and that's what drives the contemporary emphasis on meniscus preservation surgery, because we're doing everything we can to limit the likelihood of a subsequent operation, and I think that my perspective and I think the perspective of so many of us here in this room is affected and colored by the experience of the MOON group, which you could argue are meniscus repairs that have been done in an ideal situation with ACL reconstruction, but nevertheless, from the standpoint of a robust clinical database and one that has been able to provide prospective data, certainly a treasure trove of meaningful information. As far as the MOON group found, as far as the most common reason for reoperation, it's not ACL revision, it's not re-tear, it's meniscus procedure. So I think that that's something that's really important, and it's what kind of meniscus procedure is it? It's a medial meniscus repair. That's the number one thing that portends a new subsequent operation. So I would submit to you that we're either not as good as we should be with fixing these or potentially, and maybe outside the scope of this discussion somewhat, is maybe we're have been unsuccessful in our decision-making in terms of which one should be debrided and which one should be repaired. What are the ramifications of subsequent surgery? And this has been shown over and over again, but I think this is one of the big take-home points of what the compendium of the MOON literature has put out here in the last 10 or so years, is that subsequent surgery is perhaps the, if not the most important predictor for lower IKDCs, COOS and clinical outcomes. So everything is driving to and should be focused on limiting the amount of subsequent surgery. So with that as a backdrop, then we'll just get into some of the things like I mentioned that I think are worth thinking about. Arthroscopic surgery, we're all arthroscopic surgeons. We know that angles and visualization matters. If you can't see, you can't diagnose the pathology, make the decisions that we talked about in an instrument. So here are just a couple representative examples of some things that are difficult to see. We've got a panelist talking about root tears, and I'm sure that's going to be a subject of conversation today. Mark Miller has taught us so much about how to release the MCL. I think this could be a really powerful adjunct, dealing with a tight medial compartment. There's a more specific way or a more precise way to do it with respect to where you're putting the needle in relative to the medial epicondyle. I prefer to transilluminate here with the picture on the right shows. I put my scope along those medial soft tissues, and then I can get a good look of where I'm going and where that needle needs to be. Here's a representative example. You see a tight medial compartment, some suggestion of some pathology going on at the posterior medial aspect, either at the root or the junction between the root and the horn, but awfully difficult to see exactly what you need to see, and then obviously instrument. So we'll go ahead and make the decision to trephonate or picrest the MCL, depending on what you want to call it. But I like to bring my needle in. I transilluminate like I mentioned, and then I bring my needle in from the meniscal capsule or junction atraumatically with a constant valgus stress to titrate the effect there. And then here's what we see. And I think that the titration of the effect is important. Oftentimes you get that gratifying click or crack, which is gratifying for you. It can be a little disturbing for the junior resident or the circulator in the room who wants to get a C-arm to make sure you didn't break the tibia. But you see what this does for you and how powerful it can be in terms of getting where you need to go and seeing what you need to see in order to instrument. So I have a very low threshold to do this any time I'm working in a tight posterior medial compartment. And I have this low threshold and that's informed by the fact that we know there really isn't a whole lot of morbidity associated with this. Recent systematic review by Mark Miller's group shows us that you can expect these patients to do well clinically. They'll have a little bit of soreness. I like to tell them that they'll be a little bit more sore in the medial aspect of their knee. But there's no difference with respect to instrumented or clinical laxity. And so again, very low threshold to do this. And I think it's a really, really important adjunct. I mentioned earlier that angles matter. Obviously visualization matters. But what I tell the residents and the trainees is you should not feel shackled to viewing from a lateral portal and instrumenting through a medial portal. You should be able to feel comfortable and you should be inclined to move your scope from side to side to see what you need to see and then also to put your instrument in the right place. Here's a medial meniscus transplant actually. But you see the yield of changing the portal that you're viewing from and then instrumenting from the opposite portal to put that instrument perpendicular to the meniscal tissue. I think a lot of the times we get into trouble with some of the more all-inside devices when those devices are skiving or more oblique to the meniscal tissue. So do what you need to do to put yourself perpendicular to that tissue so you can get your stitches in the right spot. Dr. Critch has taught us a lot about these lateral meniscus oblique radial tears. So the trans-patellar tendon portal can also be a powerful adjunct and provide you the angle of attack that you need in order to put your stitches in the right spot to address those tears, which I think we all would acknowledge should be addressed in 2023. To the point about angles, the relevant neurovascular anatomy is something that we should be keeping in mind, particularly in the back of the knee. You see I always like to take a look at the axial image before I do a meniscus repair just to remind myself of where all the bad stuff is. You see the popliteal artery right there and then the perineal nerve more laterally. And I think a grasp of this anatomic knowledge is important, particularly with respect to when you're using the all-inside devices. Those things come with a preset depth stop. I typically in the cadaveric literature would suggest that that depth stop should be between 14 and 16 millimeters to limit the likelihood of iatrogenic injury to the tibial artery. Similarly, a separate cadaveric study has suggested that instrumenting from that medial portal also diminishes the likelihood of iatrogenic perineal nerve injury, which takes a little bit more imagination for me to think about. I'm more concerned about the artery, but nevertheless I think it's important to understand where those vital neurovascular structures are relative to the ends of those sharp objects that we're going to be using to fix particularly those posterior tears. As far as inside-out repairs, I borrow a concept from aviation, which is called crew research management, and it's something that pilots spend a lot of time talking about with before and during when they get started. It's all contingent upon good communication. For those of you that do the inside-out repairs, you understand that oftentimes you'll be the one with the scope in your hand, with the zone-specific cannula. You've got a tech feeding those needles in, and then you've got the trainee oftentimes or the fellow that's got their head down in the sand and getting splashed with water and everything like that. There's a lot of moving parts going on, and so I like to just take a minute before we get started to make sure that everybody understands who's doing what, what go, go, go means, what stop means. Establishing those roles and responsibilities are really important, to the point about limiting the amount of moving parts. There's some, I think, really useful proprietary devices on the market that allow you to advance needle yourself, and so that takes basically the tech from the back table out of the equation, which again, less moving parts, the better. From the standpoint of the open approach, I think it's important to bias your medial and lateral incisions inferiorly. If you think about the trajectory of the needle, it's typically coming from a superior to inferior direction down underneath the condyle, and so I think that when people struggle visualizing the back there with their retractors in, the tendency is to put that retractor too high. So really I emphasize the fact that that incision should be two-thirds below the joint line, and when I'm approaching the knee, approaching the back of the knee, I'm really trying to get that ribbon retractor, the sterile spoon back there where it needs to be. Kevin Bonner's article in Inside Out Repair is an oldie but a goodie and gives you some really nice cartoons there to make sure that you understand the relevant neurovascular anatomy and the intervals through which you should be dissecting both medial and laterally. But the angle is really important there. I think so oftentimes when you're fixing a bucket handle or something like that, you need to avoid the tendency to just bias all of your vertical mattress stitches on the upper aspect of the meniscus, and if you do that, oftentimes you'll find that that meniscus flips up. And so again, by bias everything inferiorly and really respecting the fact that those needles are going to be coming from superior to inferior, it really puts you in a nice spot to get those needles on the underside of the meniscus and reduce that back down in the anatomic position. What about ramp lesions or the so-called ramp lesion, which is a posterior medial capsular injury? Dr. Musal has taught us a lot about this in terms of the incidence. You see on the left there the standard or the very typical sagittal MRI cut. You see that posterior bone bruise which you should not normally see in the setting of an ACL. I think that that's a common mistake that people make is when they're ripping through those sagittal images they see that posterior bone bruise and they're thinking pivot shift. We all know that that bone bruise tends to be more lateral, the pivot shift bone bruise pattern. That bone bruise pattern should really get your spidey sense going. You also see that intervening signal in the back of the meniscus there. The HSS group has shown us that these can be extraordinarily common too with an incidence of upwards of 40%. I think that we should be looking out for these. There are certainly some fairly compelling biomechanical data to suggest that these injuries are important and can have a particularly deleterious effect on the rotational stability of the knee. I think that really that's going to inform the remarks I'm going to make here in a second about whether or not to fix these because this has been to some extent a matter of controversy. Which one should we be repairing? In the literature previous authors have discriminated between stable and unstable repairs. That distinction hasn't really ever made much sense to me. I like to think about it more in terms of the chronicity and the propensity for healing. There's two different cases here, both a right knee looking from the back through a modified Gilquist portal. What you see here is the picture on the left. It's a chronic injury. It's those tear pads, the edges of the tear are synovialized versus on the right, this is an acute injury. That was the video that I was playing in the previous slide. But the tissues are much more hemorrhagic. So I think that of those two, I would suggest to you that the healing potential is probably greater on the right. And I would have a lower threshold to repair the tear on the left. And then I think in the setting of concomitant MCL injuries, I really worry, I think about these ramp lesions as a continuum or a spectrum of pathology. And so I think with a concomitant medial-sided injury, I have a lower threshold for going ahead and addressing these for the reasons that I mentioned earlier. As far as how to go about repairing these things, there's a bunch of different ways to skin this cat. Many of authors have suggested that you can get away with fixing these via an all-inside approach. I found this cartoon, and I think this is helpful. Because what I worry about with the isolated all-inside approach is that you see that tissue on the left there that starts falling down the back of the tibia. It's hard for me to imagine being able to have that reduced to the back of the meniscus through a sole isolated all-inside approach. So this technique involves, through a posterior medial portal, actually reducing that tissue up to the back of the meniscus and then fixing it, which I think makes a lot more sense. That being said, my preferred repair technique involves instrumenting through a posterior medial portal. And I close my eyes for a minute and picture, I do a fair amount of shoulder surgery. And so I picture fixing a shoulder labrum. And so I bring my suture lasso in through a posterior medial portal. We'll talk about that in a minute as far as how to go about putting yourself in the best spot. But you take a nice big bite of that posterior medial capsular tissue in the meniscus, and then you can shuttle a suture in and then tie it. And I think that really nicely co-ops those tissues in the back and then also decreases that potential space that I think really sets you up nicely for healing. And I think the proof is in the pudding from the standpoint of what the literature tells us in terms of how these repairs do. But unsurprisingly, the tears that are involving a repair using a suture hook probably heal at a higher rate. And I think it's for a lot of the reasons that we mentioned from the standpoint of just being able to get those tissues back up, reduced in an atomic position. And so just a technical point here I think is really, really important. I think when folks tend to struggle working in the back of the knee, they do so because they put their posterior medial portal probably a little bit too distal and a little too medial. And so if you really err on the side of putting your portal proximal and a little bit more posterior, which can be more uncomfortable I understand, but you're doing it under spinal needle visualization, it really sets you up nicely and can put that instrument in a great spot in order to get into the back of the knee where you need to go. And so high and more lateral I think is the way to go for that posterior medial portal. And then I'll just close with just some brief comments on biologic augmentation. Dr. Leprod has taught us that the marrow venting can be an extraordinarily powerful adjunct. And doing so with meniscus tears in isolation, you can receive rates of healing comparable to those that are done, as I mentioned earlier, in the setting of an ACL reconstruction, which is probably from a biological standpoint as good as it gets. A number of authors have described using fiber and clots that can be prepared on the back table with a glass beaker in order to interpose that between the repair interface. Dr. Flanagan has taught us that PRP can be a powerful adjunct to these meniscus repairs and can do a lot towards increasing healing. And bone marrow aspirate concentrate, I think that a lot of the basic science is compelling, but the jury's still out from the standpoint of clinical data to justify the potential morbidity and certainly the cost associated with that. So in summary, with meniscus repairs, pick the right ones to repair and get it right the first time, which is the crux of the matter here for us this morning, and I'm looking forward to learn a lot from the panelists. We talked about the importance of being able to see what you need to see and using adjuncts to put yourself in the right spot to diagnose the pathology and instrument in an atraumatic and effective fashion. Know the neurovascular anatomy knowledge is power. The all-inside technical considerations, again, I think that communication between the team members is really, really important. Ramp lesions, my bias is to fix them and fix them anatomically. And then biological augmentation, again, I think a lot of these tears can be enhanced from the standpoint of putting the biology in the right spot. So thank you very much. Thank you. Very nice, Andy. Can I ask into the group, when you do a standard bucket handle meniscus repair, do you like using inside-out sutures or do you prefer the all-inside? So a show of hands, who's still using inside-out sutures for that? Okay, very good. And who's going all inside, most of the room, I guess? Half-half, so that's very interesting. And when you have a bucket handle tear, you know, say a four centimeter tear, how many stitches do you put? You put five stitches, you're good with it? You put 25 stitches? Is there a sweet spot? If I'm doing inside-out and it's about half the meniscus, I would probably put about anywhere from six to eight in that. If I'm doing an all-inside device, it's probably four. Can I hear anything higher? Six to eight, you go ten? Can I hear 12? How many, do you use 20 sutures? No, it's very interesting. I think there's very little knowledge on how far you space those sutures out, you know? So I always find it interesting, I go to these conferences. You know the worst day for a patient to come to your office? You know that day? The day you return from a conference, right? Trying to apply something new, so don't, but it's just interesting to hear everyone. And one thing, Andy, is interesting too, you showed the failure rate of the ramp repair based on the suture hook versus the all-inside. Do you buy that? Four percent failure is okay, I buy that. Twenty-five percent failure with all-insides? It's okay, just speak up. I think that, you know, it's how we define failure, you know, do we define failure with a subsequent surgery, you know, second look, you know, MRI, it's tough to know, and I don't think that those authors glean that. But I agree that those are rates that are kind of worth raising your eyebrow to for sure. That's interesting. I think you can grab sometimes maybe too much tissue if you use the suture hook, also something we don't really know exactly how much tissue to use. Anyway, great talk.

meniscus repair

meniscus preservation surgery

arthroscopic surgery

neurovascular anatomy

ramp lesion repair